Management of HIV-related lymphoma in HIV treatment centres in North Thames Region.

We describe an audit of lymphoma care in HIV-positive patients. In the smaller units (< 500 patients) areas of potentially sub-optimal care were identified.

Management of HIV and hepatitis B or C co-infection in 15 HIV treatment centres. Disparity between protocols and practice.

Our aim was to ascertain current guidelines and clinical practices prevalent in HIV treatment centres in the North Thames Region of England on the care of patients co-infected with HIV and hepatitis B or C. A self-completed postal survey of clinic guidelines and retrospective case-note reviews was performed. Fifteen of the 27 units completed the survey and generally had clinic guidelines consistent with current national guidelines. Stated policy was usually to screen HIV patients for hepatitis B virus (HBV) and hepatitis C virus (HCV) and to offer specific therapy for the hepatitis as well as the HIV. Many units were unable to contribute cases to the case-note review, probably through lack of case-identification, and therefore 11 units contributed 27 case-note reviews on HIV/HBV and five units contributed 11 case-note reviews on HIV/HCV. Fifty-six percent (25/45) of patients of HBV patients were HBeAg+ve and 88% (22/25) of these had received specific hepatitis B therapy although for 59% (13/22) this was with lamivudine as part of a highly active antiretroviral therapy regimen. None of the HIV/HCV patients had received or been referred for HCV-specific therapy. Testing for hepatitis A immunity in HBV or HCV patients with a view to vaccination was done in only 50% although 96% of HIV/HCV patients had been screened for HBV. There are significant differences between the clinics' intended and actual management of HIV and chronic viral hepatitis co-infection.

Provision of Chlamydia trachomatis screening in family planning clinics and emergency contraception in genitourinary medicine clinics: a collaborative cross-speciality survey.

Two surveys were undertaken to review (1) provision of Chlamydia trachomatis screening by family planning (FP) clinics in the London region and (2) access to emergency contraception (EC) from genitourinary#10; medicine (GUM) clinics within the former North Thames region. The findings from the first survey suggest that there is insufficient screening (and treatment) in vulnerable groups attending FP clinics. Results#10; from the second survey show that hormonal EC is widely available from within GUM clinics, and those clinics also provide a range of other contraception services. However, these details may not be widely#10; recognised either by policymakers or the general public. #10;

Diagnostic utility of bone marrow sampling in HIV positive patients.

OBJECTIVE: To evaluate the diagnostic utility of bone marrow (BM) sampling in HIV positive patients. DESIGN: Retrospective cohort analysis. SETTING: Specialist HIV/AIDS service in London. SUBJECTS: 215 consecutive HIV infected patients undergoing 246 BM samplings for investigation of pyrexia without localising signs, haematological abnormalities, or staging/investigation of lymphoma. MAIN OUTCOME MEASURE: Diagnostic yield from (and impact on management of) BM sampling. RESULTS: Of 122 BM samples taken to investigate pyrexia, 33 (27%) revealed the cause on microscopy: unexpected lymphoma in seven (6%), mycobacteriosis in 25 (20%), and toxoplasmosis in one (1%). Marrow infiltration was confirmed in 11 of 38 BM samples taken for staging/investigation of lymphoma/leukaemia. In afebrile patients, of 22 with pancytopenia, BM samples showed HIV associated changes in 17 and specific diagnoses in five (mycobacterial infection in three, haemophagocytic syndrome in one, and megaloblastic change due to vitamin B-12 deficiency in one); of 21 with isolated thrombocytopenia, 20 (95%) BM samples showed immune thrombocytopenic purpura to be the cause and the remaining patient had BM changes of aplasia; of 29 with isolated anaemia, 28 had BM changes of HIV associated dysplasia/erythroid dysplasia and one had unsuspected iron deficiency; all 10 with isolated leucopenia/neutropenia had BM changes ascribed to HIV infection exacerbated by concurrent sepsis or medication; of four BM samples taken for other reasons, one showed mycobacterial infection. CONCLUSIONS: BM sampling has diagnostic utility in HIV infected patients with pyrexia without localising signs, pancytopenia, and staging/investigation of lymphoma; this test has little value in the investigation of afebrile patients with isolated thrombocytopenia, anaemia, or leucopenia as HIV is usually the underlying cause.

AIDS-related lymphoma: an emerging epidemic.

Acquired immunodeficiency syndrome-related lymphoma is a serious opportunistic complication of human immunodeficiency virus (HIV) infection which is predicted to increase in frequency over the next few years. The presence of this malignant process in HIV-related individuals, who are already immunocompromised, constitutes a major cause of morbidity and mortality, determining both therapy and prognosis.

Haemolytic anaemia complicating Epstein-Barr virus infection.

Hepatitis is a well-recognised complication of Epstein-Barr virus (EBV) infection that usually resolves spontaneously. Jaundice occasionally results from the unusual complication of autoimmune haemolytic anaemia rather than hepatitis. Two adult patients are described with infectious mononucleosis-related hepatitis who also developed significant haemolysis, a situation that could have led to diagnostic delay and a deleterious outcome. Haemolysis should be considered in all patients who become jaundiced after infectious mononucleosis. The management of this potentially fatal complication is discussed.

Dual-centre, double-blind, randomised trial of lymphoblastoid interferon alpha with or without steroid pretreatment in children with chronic hepatitis B.

Thirty-five children with chronic HBV infection, HBV-DNA and eAg serum positivity, and HBcAg in liver tissue were treated with lymphoblastoid human interferon alpha with (16 cases) or without (19 cases) prednisolone pretreatment. The patients were double-blind randomized to receive steroid or placebo for 4 weeks, followed after 2 weeks by 5 or 10 MU/m2 interferon for 12 weeks. The e anti-e seroconversion rate reached 48%, which is much higher than the spontaneous seroconversion rate. The influence of "prednisolone priming" was not statistically significant. HBeAg clearance was similar in both groups (44% after prednisolone/interferon and 53% after interferon alone). The response to either treatment did not correlate with the pretreatment serum transaminase. HBV-DNA or degree of histological activity. Interferon was well tolerated, the side effects being less severe than in adults, and never led to suspension of the treatment.

Serum concentrations of von Willebrand factor and soluble thrombomodulin indicate alteration of endothelial function in inflammatory bowel diseases.

Serum concentrations of immunoreactive von Willebrand factor (vWF) and soluble thrombomodulin (TM), and vWF multimer patterns were measured to assess endothelial function in patients with inflammatory intestinal diseases. In Crohn's disease and acute infective diarrhea, vWF concentrations were significantly higher than in normal controls. In all patient groups, multimeric analysis of vWF and the concentration of serum TM were not different from normal controls. The results indicate alteration of endothelial function in inflammatory intestinal disorders. They may be compatible with the presence of localized vasculitis, but indicate that systemic endothelial destruction does not occur in inflammatory bowel disease.

A case cluster of possible tissue invasive gonorrhoea.

OBJECTIVE: To describe a cluster of patients presenting with severe symptoms and infected with an unusual strain of Neisseria gonorrhoeae. SETTING: A north London Department of Sexual Health. PATIENTS: Five patients were linked by reported sexual contact or other epidemiological evidence as part of a cluster of gonococcal infection. Cultured N gonorrhoea were subtyped by serological (serovar) and cultural (auxotype) methods and antibiotic sensitivities measured by minimum inhibitory concentration (MIC). RESULTS: Four of the patients had severe gonorrhoea-related systemic or extragenital symptoms: disseminated gonococcal infection with oligoarthritis (1 patient), acute pelvic inflammatory disease (1 patient, who was also chlamydia positive) and tender inguinal adenopathy (2 patients). The fifth patient was asymptomatic. N gonorrhoeae was isolated in four of the patients. All four organisms had identical MICs. Three of the organisms were subtyped and found to be the same rare strain (serovar 1A1, auxotype NR). CONCLUSION: This case cluster provides evidence for strain-related virulence in an uncommon gonococcal subtype.

A typhus-like illness caused by acute HIV seroconversion.

A patient is described in whom an acute human immunodeficiency virus seroconversion illness occurred following a trip to southern Africa. The presentation was strikingly similar to that of African tick typhus and could only be distinguished by serological testing.

PIP: Physicians admitted a 27-year-old man to the Hospital for Tropical Diseases in London, England because he had had a fever for 2 days (39 degrees Celsius) and a generalized erythematous maculo-papular rash for 1 day. These symptoms appeared soon after returning from a 5-month visit to Botswana, South Africa, and Zimbabwe. Much of his visit included visits to rural areas where insects bit him frequently. He experienced vaginal intercourse with some women, but did use condoms each time. He had his last sexual experience 10 days before becoming ill. When the physicians examined the patient, they noted many small palatal ulcers, bilateral inguinal lymphadenopathy, and a 5 mm diameter nontender ulcer of the glans penis. At this point, they believed he suffered from tick typhus and primary syphilis. Laboratory tests showed 29% of his white blood cells to be lymphocytes and Treponema pallidum in the penile ulcer exudate. The physicians then prescribed daily intramuscular injections of 600 mg procaine penicillin for 10 days. The rash vanished 2 days and the fever and ulcers vanished 5 days after treatment began. Blood tests later done while still in the hospital revealed him to be HIV-I p24 antigen positive, but anti-HIV-I and -II negative. 2 months later, however, he tested HIV-I positive, but negative for rickettsiae, arboviruses, cytomegalovirus, and enteroviruses. Since he later tested HIV positive and negative for pathogens causing typhus, it was concluded that his typhuslike illness was a result of acute HIV seroconversion. Other physicians have also noted similar manifestations of seroconversion in HIV positive patients. They recommended that physicians should consider HIV seroconversion illness when a patient who recently traveled to the tropics or is sexually active exhibits an acute febrile condition with maculo-papular rash.

Which patients with chronic hepatitis B virus infection will respond to alpha-interferon therapy? A statistical analysis of predictive factors.

Twenty-one pretreatment variables were assessed for their significance in response prediction using data from 114 patients given alpha-interferon for chronic hepatitis B virus infection. In those patients who had received a minimum of 90 million units per m2 total dose over 12 weeks, a negative anti-human immunodeficiency virus antibody status (p less than 0.001), chronic active hepatitis on liver biopsy (p less than 0.005), high AST level (p less than 0.001), low hepatitis B virus DNA level (p less than 0.001) and a history of acute hepatitis (p less than 0.005) were all associated with an increased likelihood of response on univariate analysis. On stepwise logistic regression analysis, hepatitis B virus DNA, AST and a history of acute hepatitis predicted response independently (p less than 0.05). The most reliable combination of predictive factors was a negative anti-human immunodeficiency virus antibody status, with either a positive history of acute icteric hepatitis and AST greater than 45 IU per liter or no history of acute icteric hepatitis and AST greater than 85 IU per liter, which predicted response in 77% with a specificity of 79% (p less than 0.001). The loss of HBsAg in addition to HBeAg and hepatitis B virus DNA was more likely to occur in patients with chronic infection of less than 2 years duration (p less than 0.001).

Histological improvement after anti-viral treatment for chronic hepatitis B virus infection.

Sequential liver biopsies were taken from 66 patients with chronic hepatitis B virus (HBV) infection being followed in randomised controlled trials of therapy with alpha interferons or adenine arabinoside 5'-monophosphate. In the group of 23 patients responding to treatment with the permanent loss of HBe antigen and HBV-DNA from their serum, there was a significant reduction in hepatic inflammatory activity and none developed cirrhosis. In contrast, inflammatory activity continued in the group of 24 patients that did not respond to therapy, and in the group of 19 patients who received no therapy. Two untreated controls progressed to cirrhosis. Further studies confirmed that in those clearing HBeAg and HBV-DNA from the serum, HBcAg and HBeAg were also lost from the liver. This study demonstrates that, as in natural seroconversion, successful treatment of chronic HBV infection is associated with loss of hepatic as well as serum markers of HBV replication, and is followed by a reduction in hepatic inflammation. Antiviral therapy may prevent progression to cirrhosis in some cases.

Clinical features and management of two cases of Streptococcus milleri chest infection.

We report 2 cases of Streptococcus milleri infection of the lung. One patient, a 58-year-old woman, presented with a large abscess in a previously normal lung, the other, a 53-year-old man, had a secondary infection of lung previously scarred by tuberculosis and surgery. Both patients had severe dental caries. Four weeks of therapy with high dose antibiotics and physiotherapy were required. Invasive techniques were needed to isolate the organism.

Human lymphoblastoid interferon does not increase survival when added to mitozantrone in the treatment of hepatocellular carcinomas.

Human lymphoblastoid interferon, in an initial dose of 2.5 MU m-2 weekly i.m., was given with mitozantrone 12 mg m-2 i.v. every 3 weeks to 15 patients with hepatocellular carcinoma. The survival curve for these patients was worse than that of 15 patients previously treated with mitozantrone alone; there were more long-term survivors in those not given interferon; more side-effects were seen in the group given interferon. The addition of interferon to mitozantrone in the management of hepatocellular carcinoma is not recommended.